Inspection on 12/01/06 for Southampton Way, 296-298

This inspection was carried out on 12th January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Southampton Way, 296-298 12/01/09

Southampton Way, 296-298 07/02/07

Southampton Way, 296-298 04/03/05

Southampton Way, 296-298 22/09/04

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Southampton Way, 296/298 296/298 Southampton Way London SE5 7HQ Lead Inspector Pam Cohen Unannounced Inspection 12th January 2006 10:00 Southampton Way, 296/298 DS0000007098.V277638.R01.S.doc Version 5.1 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Southampton Way, 296/298 DS0000007098.V277638.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Southampton Way, 296/298 DS0000007098.V277638.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Southampton Way, 296/298 Address 296/298 Southampton Way London SE5 7HQ Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 020 7252 6748 020 7252 6748 admiin@sway.equinoxcare.org.uk Equinox Mrs Oluwatoyin Ann Adesoye Care Home 13 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (13) of places Southampton Way, 296/298 DS0000007098.V277638.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th September 2005 Brief Description of the Service: Southampton Way is a registered care home managed by Equinox to provide 24-hour care for 13 males with mental health and/or substance misuse problems. The service users are mostly Afro-Caribbean. The home is on three floors and accommodation is in fully equipped studio flats. There are also communal facilities of a laundry, kitchen, lounge/dining room, smoking room and a garden. There is on street parking. The home is near Peckham High street, rail and bus links and community health and leisure facilities. On the day of inspection there was one vacancy. Southampton Way, 296/298 DS0000007098.V277638.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place in the early afternoon of 12th January 2006. The manager was present and facilitated the inspection. The inspector spoke briefly to one service user. The previous inspection showed that the home was functioning well and this inspection was mainly to follow up on those requirements which had been made in September 2005. What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Southampton Way, 296/298 DS0000007098.V277638.R01.S.doc Version 5.1 Page 6 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Southampton Way, 296/298 DS0000007098.V277638.R01.S.doc Version 5.1 Page 7 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 4.5. Prospective service users have a good introduction to the home before admission. EVIDENCE: A service user was in the process of being admitted to the home at the time of inspection. The manager explained the process which is happening, which is in line with good practice. All service users have an individual license agreement and this is not signed until the end of a successful 3 month review period. Southampton Way, 296/298 DS0000007098.V277638.R01.S.doc Version 5.1 Page 8 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9. Individual planning, although good on the basics, did not always clearly chart changes and reflect current need. Risk assessments do not always trigger strategies to manage areas of risk. Service users are supported well, to take decisions about their life. EVIDENCE: All service users have care plans, which are drawn up with them and contain those areas where help is needed. There are aims, with action needed to achieve these aims by the service users and staff and these are reviewed 6 monthly. Care plans are monitored through key working sessions and in individual daily diaries. The basics are good but the home needs to consider how to adequately chart the changing needs and aspirations of service users. For instance, one service user is finding it hard to engage with the home and although it was clear that staff are aware of the situation, nothing was recorded on his individual plan. Risk assessments are done on admission and are updated regularly, but risk management strategies were not on two files, for those areas where risk was identified. Southampton Way, 296/298 DS0000007098.V277638.R01.S.doc Version 5.1 Page 9 Files and daily notes showed clearly that service users make decisions as to how they live. In those instances where this has been limited, for instance with one service user where it was agreed that self –medication was not in his best interests, the decision is clearly recorded. Southampton Way, 296/298 DS0000007098.V277638.R01.S.doc Version 5.1 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,17. Service users are well supported in their personal development needs. They are also provided with a nutritious diet as well as supported to be able to cater for themselves. EVIDENCE: There was much evidence on files that staff support service users to look for employment, pursue further education and either follow known social activities or find new ones. They also support service users to manage their finances. The manager was clear that the main aim with food provision is helping service users to be able to look after their own needs. Breakfast foods are provided and the aim is first of all for service users to take their own breakfasts in the communal dining room and to be able then to prepare their own breakfasts in their flats. There is a communal evening meal with a menu chosen by service users. However again the aim is that with weekly cooking sessions with staff, service users should be able to prepare their own meals in order to be ready to move on to more independent living. Dietician’s advice has been sought both in relation to the menu and for individual service user’s needs if they are diabetic or overweight. Southampton Way, 296/298 DS0000007098.V277638.R01.S.doc Version 5.1 Page 11 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 Service users can be confident that the health care needs will be met. EVIDENCE: There was clear evidence from talking to the manager and checking files that service users’ physical and emotional health needs are recognised and met. Service users are supported to access GP’s and professionals such as dentists. There is also liaison with the local multi-disciplinary and mental health teams so that appropriate interventions can be offered when needed. Monitoring is through key worker sessions and CPA meetings. Southampton Way, 296/298 DS0000007098.V277638.R01.S.doc Version 5.1 Page 12 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Both these standards were seen to be met at the last inspection. EVIDENCE: Southampton Way, 296/298 DS0000007098.V277638.R01.S.doc Version 5.1 Page 13 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 Service users’ need to know that the ongoing problem with leakage will be addressed. EVIDENCE: At the last inspection it was seen that the home was comfortable, homely and clean. It is safe and the spacious bedsit flats promote independence. The only concern noted with the environment was a problem with leakage from ceilings. The two sites where that had caused a problem at the last inspection have been repaired. However the manager confirmed that another leak has occurred in the storeroom and has not yet been able to be repaired. This problem has now been ongoing for a considerable period of time and the recommendation in the last report that it should be dealt with is now a requirement. Southampton Way, 296/298 DS0000007098.V277638.R01.S.doc Version 5.1 Page 14 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): At the last inspection staff were seen to be well trained, supported and motivated. On this visit a service user said that they were good and that he would mark them with 9 out of 10. EVIDENCE: Southampton Way, 296/298 DS0000007098.V277638.R01.S.doc Version 5.1 Page 15 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,40. The process to up-date policies and procedures needs to be completed in order to ensure service users’ protection. EVIDENCE: At the last inspection the manager was found to be competent and at this inspection she confirmed that she is still on target to finish her NVQ 4 in management course this year. Since the last inspection there have been regular person in control visits, with the reports sent to the CSCI. Policy and procedure documents are still being updated and the manager believes that this process would be finished shortly. Southampton Way, 296/298 DS0000007098.V277638.R01.S.doc Version 5.1 Page 16 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 x 2 x 3 x 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 x 23 x ENVIRONMENT Standard No Score 24 2 25 x 26 x 27 x 28 x 29 x 30 x STAFFING Standard No Score 31 x 32 x 33 x 34 x 35 x 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 x 2 x LIFESTYLES Standard No Score 11 x 12 3 13 x 14 x 15 x 16 x 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score x 3 x x 2 x 3 2 x x x Southampton Way, 296/298 DS0000007098.V277638.R01.S.doc Version 5.1 Page 17 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA6 Timescale for action 15(1) The registered person must 31/03/06 ensure that all service users’ individual plans reflect changes and current need. 13(4)(b) The registered person must 31/03/06 ensure that risk management strategies are in place where risk has been identified. 13(4) The registered person must 30/06/06 ensure that the ongoing problem with leakage, is resolved. 9(1)(2)(b)(i) The registered person must 30/06/06 ensure that the registered manager achieves the NVQ 4 in management as soon as possible. Sch3&4 The registered person must 30/04/06 3(10) 24(5) ensure that all policy and procedure documents are reviewed and updated. Previous target dates of 31/11/2004, 30/08/2005 and 31/12/2005 unmet. Regulation Requirement 2. YA9 3. YA24 4. YA37 6. YA40 Southampton Way, 296/298 DS0000007098.V277638.R01.S.doc Version 5.1 Page 18 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA24 Good Practice Recommendations It is recommended that the registered person takes advice regarding ongoing problems with leakages in the building, and takes any necessary actions. Southampton Way, 296/298 DS0000007098.V277638.R01.S.doc Version 5.1 Page 19 Commission for Social Care Inspection SE London Area Office Ground Floor 46 Loman Street Southwark SE1 0EH National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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